Effect of prosthetic mitral valve geometry and orientation on flow dynamics in a model human left ventricle

Pulsatile flow dynamics through bileaflet (St Jude and Duromedics), tilting disc (Bjork-Shiley and Omniscience), caged ball (Starr-Edwards), pericardial (Edwards) and porcine (Carpentier-Edwards) mitral valves in a model human left ventricle (LV) were studied. The model human ventricle, obtained from an in situ diastolic casting, was incorporated into a mock circulatory system. Measurements were made at various heart rates and flow rates. These included the transvalvular pressure drop and regurgitation in percent and cm3 beat-1. The effect of valve geometry and the orientation of the valve with respect to the valve annulus was analyzed using a flow visualization technique. Qualitative flow visualization study indicates certain preferred orientations for the tilting disc and bileaflet valve prostheses in order to obtain a smooth washout of flow in the LV chamber.     

Laser anemometry measurements of pulsatile flow past aortic valve prostheses

Experimental results are presented on physiological pulsatile flow past caged ball and tilting disc aortic valve prostheses mounted in an axisymmetric chamber incorporated in a mock circulatory system. The measurements of velocity profiles and turbulent normal stresses during several times in a cardiac cycle were obtained using laser-Doppler anemometry. Our results show that with increased angle of opening for the tilting disc valves, a large but locally confined vortex is observed along the wall in the minor flow region throughout most of the cardiac cycle. The turbulent normal stresses measured downstream to the tilting disc in the minor flow region parallel to the tilt axis were found to be larger than those measured downstream to the caged ball valves. Comparison of measurements with steady flow at flow rates comparable to peak pulsatile flow rate show that the turbulent normal stresses are larger by a factor of two in pulsatile flow with a frequency of 1.2 Hz.     

Dynamics of left ventricular wall and mitral valve mechanics--a model study

The relation between global left ventricular pumping characteristics and local cardiac muscle fiber mechanics is represented by a mathematical model of left ventricular mechanics in which the mitral valve papillary muscle system is incorporated. The wall of the left ventricle is simulated by a thick-walled cylinder. Transmural differences in fiber orientation are incorporated by changing the direction of material anisotropy across the wall. The cylinder is free to twist. The upper end of the cylinder is covered by a thin, flexible sheet, representing the base of the left ventricle. The mitral valve is incorporated in this sheet. The tips of the mitral leaflets are connected by chordae tendineae to the papillary muscles which are attached to the bottom of the cylinder. Canine cardiac cycles were simulated for various end-diastolic values of left ventricular volume (25-120 ml, control 60 ml), left atrial pressure (0-2.7 kPa, control 0.22 kPa) and aortic pressure (5-11 kPa, control 11 kPa). In this wide range of preload and afterload mechanical loading of the muscle fibers appeared to be distributed quite evenly (SD: +/- 5% of control value) over all muscular structures of the left ventricle, including the papillary muscles.     

In vitro pulsatile flow velocity and shear stress measurements in the vicinity of mechanical mitral heart valve prostheses

A three beam laser Doppler anemometer system was used to study the flow fields created by various types of mitral heart valve prostheses under physiological pulsatile flow conditions. The prosthetic valves studied were: Beall caged disc valve, Bjork-Shiley tilting disc valve, Medtronic-Hall tilting disc valve and St. Jude bileaflet valve. The results indicate that all four prosthetic valve designs studied create very disturbed flow fields with elevated turbulent shear stresses and regions of flow separation and/or stagnation. The observed elevated turbulent shear stresses could cause sublethal and/or lethal damage to red cells and platelets. The regions of flow separation and/or stagnation, could lead to thrombus formation and/or tissue overgrowth on the valve structure, as observed on clinically recovered prosthetic valves.     

Steady flow development past valve prostheses in a model human aorta—I. Centrally occluding valves

In this paper, laser-Doppler anemometry measurement of steady flow development in a model human aorta has been reported. Studies were made with uniform entry flow at the root of the aorta and our measurements showed the establishment of a pair of Dean vortices in the mid-arch region. Subsequently, the nature of flow development past centrally occluding caged ball valves in the model aorta was investigated. Our studies showed that in the ascending aorta, an asymmetric velocity profile is obtained with larger velocity gradients towards the inner wall of tertiary curvature (anatomically the left lateral wall) with centrally occluding valves. The peripheral flow past these valves prevented the development of Dean vortices in the mid-arch region. The caged ball valves at the root of the aorta had no discernible effect on the velocity profiles in the brachio-cephalic artery.     

Steady flow development past valve prostheses in a model human aorta—II. Tilting disc valves

The flow development in the model human aorta with uniform entry as well as with centrally occuluding valves mounted at the root of the aorta was described in Part I of this two-paper sequence. Part II deals with the flow development in the model aorta with tilting disc valves mounted at the root of the aorta. Bjork-Shiley and Hall-Kaster tilting disc valves were mounted in three different orientations with respect to the root of the aorta. The velocity profiles and turbulent stresses were measured with laser-Doppler anemometry. Our results under steady flow conditions in the model human aorta show quantitatively that the flow development in the ascending aorta as well as in the brachio-cephalic artery are strongly dependent on the orientation of the tilting disc valves. With the valves tilting towards the outer wall of curvature, our results suggest a tendency for flow separation at the flow divider region of the brachio-cephalic artery.     

Coenzyme Q10 and key enzyme activities in papillary muscle related to left ventricle function in mitral valve disease

Coenzyme Q₁₀ (CoQ₁₀) was studied in papillary muscle from 18 patients (52–67 years, 2 females) subjected to open heart surgery due to mitral valve disease. In addition the enzyme activities of lactate dehydrogenase (LD) with its five isozymes, citrate synthase (CS) and mitochondrial CK (CK-MIT) were determined. Myocardial function was assessed by means of left ventricle (LV) angiography. CoQ₁₀ averaged 0.39 (range 0.26–0.59) g × mg^–1 dw. On an individual basis CoQ₁₀ was related to CS activity although not as closely as CK-MIT (r = 0.45, p<0.05 versus r = 0.86, p<0.001). The ratio (CoQ₁₀) × (CS activity)^–1 was calculated to represent mitochondrial quality. The level of LD₃ fraction increase was used to mark for the degree of metabolic stress in the heart. LD₃ fraction was negatively related to the quality index (r = –0.71, p<0.001). Thus, those with a low CoQ₁₀ per unit of CS activity had also a high LD₃ isozyme fraction. In a subset of 12 patients with isolated mitral regurgitation due to myxomatous valve degeneration, CoQ₁₀ and the ratio CoQ₁₀ over CS decreased with the degree of LV function impairment (r = –0.58, p<0.05 and r = –0.68, p<0.05, respectively). The quality index takes into account not only enzyme activity but also the potential for control of free oxygen radicals.     

Disc erosion in Models 103 and 104 of Beall mitral valve prostheses

Three cases of severe disc variance and erosion of the Teflon-disc Beall mitral valve prosthesis (Models 103 and 104) are reported. In two patients, the Beall mitral valves were excised and replaced with two Bj?rk-Shiley mitral valves. The remaining patient did not survive, and at autopsy, the lens was found at the aortic bifurcation level. Because of this potentially lethal complication, careful follow-up of patients with Beall mitral valve prostheses (Models 103 and 104) is recommended.     

Experimental study of physiological pulsatile flow past valve prostheses in a model of human aorta--I. Caged ball valves

Pulsatile flow development past a caged ball valve in a model human aorta was studied using laser Doppler anemometry. Velocity profiles measured in the ascending aorta and in the mid-arch region were strongly influenced by the geometry of the valve at the root of the aorta. Velocity profiles distal to the valve were asymmetric with jet-like flow in the peripheral region having larger velocity magnitudes towards the left lateral wall. In early diastole, a streamwise vortex motion was observed throughout the model aorta with fluid moving towards the downstream direction along the left lateral wall and reversed flow along the right lateral wall. With the caged ball valve at the root of the aorta, no reversed flow was observed along the inner wall of curvature in the mid-arch region.     

Tomographic PIV in a model of the left ventricle: 3D flow past biological and mechanical heart valves

Left ventricular flow is intrinsically complex, three-dimensional and unsteady. Its features are susceptible to cardiovascular pathology and treatment, in particular to surgical interventions involving the valves (mitral valve replacement). To improve our understanding of intraventricular fluid mechanics and the impact of various types of prosthetic valves thereon, we have developed a custom-designed versatile left ventricular phantom with anatomically realistic moving left ventricular membrane. A biological, a tilting disc and a bileaflet valve (in two different orientations) were mounted in the mitral position and tested under the same settings. To investigate 3D flow within the phantom, a four-view tomographic particle image velocimetry setup has been implemented. The results compare side-by-side the evolution of the 3D flow topology, vortical structures and kinetic energy in the left ventricle domain during the cardiac cycle. Except for the tilting disc valve, all tested prosthetic valves induced a crossed flow path, where the outflow crosses the inflow path, passing under the mitral valve. The biological valve shows a strong jet with a peak velocity about twice as high compared to all mechanical heart valves, which makes it easier to penetrate deeply into the cavity. Accordingly, the peak kinetic energy in the left ventricle in case of the biological valve is about four times higher than the mechanical heart valves. We conclude that the tomographic particle imaging velocimetry setup provides a useful ground truth measurement of flow features and allows a comparison of the effects of different valve types on left ventricular flow patterns.     

Time-resolved DPIV analysis of vortex dynamics in a left ventricular model through bileaflet mechanical and porcine heart valve prostheses

The performance of the heart after a mitral valve replacement operation greatly depends on the flow character downstream of the valve. The design and implanting orientation of valves may considerably affect the flow development. A study of the hemodynamics of two orientations, anatomical and anti-anatomical, of the St. Jude Medical (SJM) bileaflet valve are presented and compared with those of the SJM Biocor porcine valve, which served also to represent the natural valve. We document the velocity field in a flexible, transparent (LV) using time-resolved digital particle image velocimetry (TRDPIV). Vortex formation and vortex interaction are two important physical phenomena that dominate the filling and emptying of the ventricle. For the three configurations, the following effects were examined: mitral valve inlet jet asymmetry, survival of vortical structures upstream of the aortic valve, vortex-induced velocities and redirection of theflow in abidance of the Biot-Savart law, domain segmentation, resonant times of vortical structures, and regions of stagnantflow. The presence of three distinct flow patterns, for the three configurations, was identified by the location of vortical structures and level of coherence corresponding to a significant variation in the turbulence level distribution inside the LV. The adverse effect of these observations could potentially compromise the efficiency of the LV and result in flow patterns that deviate from those in the natural heart.     

Stresses in the closed mitral valve: a model study

In the present model study on the closed mitral valve, tensile force in the chordae tendineae is related to transvalvular pressure using a mathematical model of mechanics of the closed mitral valve. Circumferential stress as well as bending stress in the valve leaflets were neglected. Without precisely knowing the mechanical properties of the leaflet material, geometry of the leaflets was estimated by applying Laplace's law, which relates leaflet stress to leaflet curvature. Independent of shape of the mitral valve orifice, under all circumstances tensile force in the chordae tendineae was calculated to be equal or greater than half the force exerted on the mitral valve orifice by the transvalvular pressure.     

The importance of myocardial amino acids during ischemia and reperfusion in dilated left ventricle of patients with degenerative mitral valve disease

Taurine, glutamine, glutamate, aspartate, and alanine are the most abundant intracellular free amino acids in human heart. The myocardial concentration of these amino acids changes during ischemia and reperfusion due to alterations in metabolic and ionic homeostasis. We hypothesized that dilated left ventricle secondary to mitral valve disease has different levels of amino acids compared to the right ventricle and that such differences determine the extent of amino acids' changes during ischemia and reperfusion. Myocardial concentration of amino acids was measured in biopsies collected from left and right ventricles before cardioplegic arrest (Custodiol HTK) and 10 min after reperfusion in patients undergoing mitral valve surgery. The dilated left ventricle had markedly higher (P < 0.05) concentrations (nmol/mg wet weight) of taurine (17.0 ± 1.5 vs. 10.9 ± 1.5), glutamine (20.5 ± 2.4 vs. 12.1 ± 1.2), and glutamate (18.3 ± 2.2 vs. 11.4 ± 1.5) when compared to right ventricle. There were no differences in the basal levels of alanine or aspartate. Upon reperfusion, a significant (P < 0.05) fall in taurine and glutamine was seen only in the left ventricle. These changes are likely to be due to transport (taurine) and/or metabolism (glutamine). There was a marked increase in the alanine to glutamate ratio in both ventricles indicative of ischemic stress which was confirmed by global release of lactate during reperfusion. This study shows that in contrast to the right ventricle, the dilated left ventricle had remodeled to accumulate amino acids which are used during ischemia and reperfusion. Whether these changes reflect differences in degree of cardioplegic protection between the two ventricles remain to be investigated.     

Two-component laser velocimeter measurements downstream of heart valve prostheses in pulsatile flow

Elevated turbulent shear stresses resulting from disturbed blood flow through prosthetic heart valves can cause damage to red blood cells and platelets. The purpose of this study was to measure the turbulent shear stresses occurring downstream of aortic prosthetic valves during in-vitro pulsatile flow. By matching the indices of refraction of the blood analog fluid and model aorta, correlated, simultaneous two-component laser velocimeter measurements of the axial and radial velocity components were made immediately downstream of two aortic prosthetic valves. Velocity data were ensemble averaged over 200 or more cycles for a 15-ms window opened at peak systolic flow. The systolic duration for cardiac flows of 8.4 L/min was 200 ms. Ensemble-averaged total shear stress levels of 2820 dynes/cm2 and 2070 dynes/cm2 were found downstream of a trileaflet valve and a tilting disk valve, respectively. These shear stress levels decreased with axial distance downstream much faster for the tilting disk valve than for the trileaflet valve.     

Turbulent shear stress measurements in the vicinity of aortic heart valve prostheses

A two dimensional laser Doppler anemometer system has been used to measure the turbulent shear fields in the immediate downstream vicinity of a variety of mechanical and bioprosthetic aortic heart valves. The measurements revealed that all the mechanical valves studied, created regions of elevated levels of turbulent shear stress during the major portion of systole. The tissue bioprostheses also created elevated levels of turbulence, but they were confined to narrow regions in the bulk of the flow field. The newer generation of bioprostheses create turbulent shear stresses which are considerably lower than those created by the older generation tissue valve designs. All the aortic valves studied (mechanical and tissue) create turbulent shear stress levels which are capable of causing sub-lethal and/or lethal damage to blood elements.     

Pulsatile flow past aortic valve bioprostheses in a model human aorta

Pulsatile flow development past tissue valve prostheses in a model human aorta has been studied using qualitative flow visualization and quantitative laser-Doppler techniques. Experiments were conducted both in steady and physiological pulsatile flow situations and the measurements included the pressure drop across the valve, the instantaneous flow rate as well as the velocity profiles and turbulent stresses downstream to the valves. Our study shows that the velocity profiles with pericardial valves are closer to those measured past natural aortic valves. The porcine valves with a smaller valve opening area produce a narrower and stronger jet downstream from the valve with relatively larger turbulent axial stresses in the boundary of the jet. Our study suggests that the pericardial valves with turbulent stresses comparable to those of caged ball and tilting disc valves are preferable from a hemodynamic point of view.     

Thrombus in a normal left ventricle

A 47-year-old women known to have mixed connective tissue disease and hypertension, presented with acute right leg pain requiring urgent right common femoral artery embolectomy with fasciotomy. During the immediate postoperative period, full-dose heparin and oral anticoagulant therapy were started. An echocardiogram revealed an echo-dense mass in the left ventricular cavity, but no additional cardiac abnormality (figure 1). On the sixth day of admission the patient developed a cerebrovascular accident with echocardiographic disappearance of the left ventricular mass.     

An elongation model of left ventricle deformation in diastole

A numerical method of the left ventricle (LV) deformation, an elongation model, was put forth for the study of LV fluid mechanics in diastole. The LV elongated only along the apical axis, and the motion was controlled by the intraventricular flow rate. Two other LV models, a fixed control volume model and a dilation model, were also used for model comparison and the study of LV fluid mechanics. For clinical sphere indices (SIs, between 1.0 and 2.0), the three models showed little difference in pressure and velocity distributions along the apical axis at E-peak. The energy dissipation was lower at a larger SI in that the jet and vortex development was less limited by the LV cavity in the apical direction. LV deformation of apical elongation may represent the primary feature of LV deformation in comparison with the secondary radial expansion. The elongation model of the LV deformation with an appropriate SI is a reasonable, simple method to study LV fluid mechanics in diastole.